Many thanks to my friends at Don’t Forget the Bubbles for publishing this blog on a common turn of phrase

Click here to go to the blog.

(And if you enjoyed it my previous New Years offering: Year End 2020)

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Although “What I learned this week” finished a couple of years ago I still remember many of the posts fondly.

Here is a new post, written for Don’t Forget the Bubbles in the #WILTW style

Click Here: Year End 2020

Happy new year, let’s hope this is the last social distanced one for a while…

What have you learnt this week? #WILTW

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Supported by Don’t Forget the Bubbles

My #WILTW series finished a couple of years ago but I’m bringing it back to life via an audio medium during the COVID-19 Pandemic.

I am not an infectious disease or pandemic expert. I have no specific training in incident management or leadership qualification. But I do hope to start conversations about the things that challenge us, and how we might respond to them.

As regular readers will know I am a fan of acronyms so will use the following as a guide to discussions.

This first episode is just an introduction to some of these themes. I’m going to aim to record something every week.

The first podcast can be found here; with apple and android availability .

Please do feel free to comment, challenge or share any thoughts.

All the best in this difficult time, and as I say in the podcast, taking time for youself is important (including setting this aside for a while and spend time reading a book, doing some cooking or just watching some mundane television)

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“But how could they possibly have missed that?” 

“How could someone have made such a bad decision?”

“It was so obvious what they needed to do!” 

The consequence of medical error is huge & in retrospect sometimes difficult for anyone to understand how some events occur. 

In this context the publication by Prof. David Diamond of a viewpoint on “Death by Hyperthermia” is very relevant.

The case at the beginning of the paper is summarised by the Canadian Broadcasting Corporation in their piece:

‘You live in hell every day’: The tragedy of forgetting your child in the car

 What kind of person forgets a baby in the back of their car?

The wealthy do it. And the poor, and the middle class. Parents of all ages and ethnicities do it. Mothers are just as likely to do it as fathers.

It’s happened to a paediatrician [1]. 

It’s difficult to comprehend how someone, who cherishes another human being so much, could fail to remember they exist & leave them powerless in a location that could kill them. 

Why this happens is not clear but Prof. Diamond has spent a career examining possible causes. Based on available evidence he estimates that more than 400 children in the USA and other countries have been harmed after being forgotten in cars.

Those who are working to reduce the impact of medical error may be interested (and probably not surprised) to know that rather than focusing on the individual to blame we should look at the environment.  

The analogy Prof. Diamond uses is the brain memory systems that fail when people forget children in cars are the same as those causing us to forget to shut off the headlights when we arrive at a destination

Legislating car seats into the back seat has had a potential negative impact. The possibility, and the incidence, of unintentional death by hyperthermia has increased.

“Just as auto manufacturers have built-in systems that shut off headlights, we must have built-in systems that detect a forgotten child in a car.”

Prof. Diamond highlights the way our working memory interacts with our prospective memory (what you must remember to do) as a core issue. Perhaps a more telling finding is an almost universal report of a false memory that their child is in a safe location by the parent.

The parents may actually think about their child during the day and still not remember they hadn’t dropped them at nursery. Understanding why false memories occur will be key to reducing the incidence of this tragic event. 

Almost certainly “false memories” exist in medical practice as well.

A belief perhaps a result had been checked, or at least attempted to be checked.

A confidence in previous decisions which doesn’t reflect the actual events.

Death by hyperthermia due to being accidentally locked in a car.

A mistake, not due to lack of compassion, but a result of the most horrendous of cognitive deceits. If these deceits can happen to a parent & child they can almost certainly happen with a doctor & their patient.

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This post first appeared as a Twitter Thread

[1] Numerous blogs and reports, including Prof. Diamond, reference this but specific details are not publicaly available due to GDPR

I am sitting in the airport in Hong Kong reflecting on the Don’t Forget the Bubbles 2018 conference (just held in Melbourne)

It’s a paediatric conference, but goes well beyond child health, managing to bring together a rich variety of topics under the banner: “Science and Story”.

I wrote, at a similar phase of my journey home from last year’s event, about why I thought the conference had been such a success.

Don't forget the catering…

— Simon Craig (@DrSimonCraig) August 29, 2018

I’ve struggled to expand on the ‘ingredients’ although Simon’s comment is well made and the ice-cream at the afternoon break was a very popular addition this year!

What has occurred to me as I have reviewed my crowd-sourced note-taking device (i.e Twitter) is that the the balance of ingredients is very important for a successful recipe. There has been churn previously regarding the growth of non-academic conferences in that they are a little soft, and the scientific content is lacking at the expense of ‘grey’ area discussion on wellbeing, leadership and communication. This is too binary a distinction, as is the very concept of something being ‘non-academic’. But it is clear to me that the traditional conference of abstract, followed by abstract, followed by occasional keynote is increasingly less relevant to generation of health care professional who can gain information for a variety of sources now.

I am proposing it is not really the specific content that probably matters, but the proportions of type of information you are given.

Consolidate Practice 

So for #DFTB18 it was fantastic to hear Paediatric Infectious disease consultant (but also emergency medicine clinician) Dr. Mike Starr talk about decision making in childhood sepsis. I didn’t learn anything I didn’t know but it confirmed to me my current practice is on the right lines.

Mike Starr challenging the convention that gut feeling is really gut feeling

Very much agree with this.

Much “perceived" gut feeling is just good clinical acumen

Gut feeling to me is when you make a decision AGAINST the available evidence https://t.co/zDExHXuE5X#DFTB18

— Damian Roland (@Damian_Roland) August 28, 2018

Acquire New Knowledge

However it would be pretty disappointing to spend three days at an international conference to just feel validated. And there was much on offer to learn from. The “Papers that you should have read” session contained some I hadn’t, and at least a couple which will result in practice change.

References described in bubblewrap live session at #DFTB18 are here..https://t.co/t1FiWr22U5

— Ben Lawton (@paedsem) August 29, 2018

Think Differently

However practice change is easy to aspire to but in honesty rarely happens immediately post conference. What is vital, is that you are at least prompted to think differently about things.

Liz Crowe talked on parent grief and challenged us to think about the impact of our words and actions

"Doctors: you have power, far greater than you think.
You can sow that seed, at the very start of your interactions, that the death of a child was not the parent’s fault.”
– @LizCrowe2 #DFTB18

— Damian Roland (@Damian_Roland) August 29, 2018

When we say “poor quality of life,” parents hear “what you have done for the past 16 years was a waste” @LizCrowe2 #wordsmatter #DFTB18

— Charlotte Durand (@char_durand) August 29, 2018

Ross Fisher highlighting our repair process following an error, accident or life event can be more powerful than we think.

https://twitter.com/DrElbyKnits/status/1034697666507096065

Be challenged

And finally change is not easy. Coming away from a conference where you have agreed with everything isn’t helpful. There needs to be a space in which you perhaps disagree, or actively reflect on why you don’t feel comfortable.

Michelle Johnston quite correctly asked us to examine our motivations when telling patients stories. Story telling is powerful, but with that power comes great responsibility.

There is a downside to storytelling in Medicine @Eleytherius #DFTB18
If you are telling a story in Medical circles- you are appropriating another person’s story. Examine your own motives in sharing patient experiences

— Casey Parker (@broomedocs) August 27, 2018

And Warwick Teague took a hard line on the incidence of child mortality secondary to trauma. His message not universally accepted but what could not be disputed was his passion for highlighting a very real issue.

Preventable injuries are preventable. Conversations need to happen. No button batteries. No quad bikes. >145cm in adult seat. 1 supervised child on trampoline. We need to value not just lives but livelihood #dftb18 Warwick Teague pic.twitter.com/aO20btlC5C

— Bea L (@Beattherice) August 28, 2018

I am not sure how the 4 elements should be balanced, 25% each seems reasonable, but it would be useful to know others thoughts and whether I have missed out a key domain!

Thanks again to the organisers of #DFTB18 for striving to improve our practice

Thanks @DFTBubbles
I had a great time. Learnt new things, solidified others and honestly felt your conference re-affirmed my, and I suspect others, vocation despite the current challenges in the healthcare landscape.

See you in London #DFTBUK https://t.co/Udnq5VZns8

— Damian Roland (@Damian_Roland) August 29, 2018

This is a rough transcript of my talk at Don’t forget the bubbles 2018

Imagine a busy shift (Emergency Department, Ward, Clinic or Assessment Unit) with people everywhere. It’s noisy, chaotic, distracting.  What makes things feel busy? It’s communication. It’s the interaction of people, with other people. Chatting, crying, screaming, complaining, laughing, pleading, discussing. It’s all communication. It also doesn’t necessarily need to be human communication: alarms bleeping, tannoys buzzing, phones ringing.

Communication tends to increase at times of stress or demand. Busy shifts are rarely audibly ‘quiet’ ones.

Communication is at the heart of medicine. It’s at the heart of this conference. It’s what brings science & story together: The ability to communicate.

And yet for something that is so important, so fundamental, so talked about, why is it we like to think that communication is a problem others have rather than being an issue of our own?

So this isn’t a talk about the communication difficulties my patients have, it’s really about the difficulties I, or you, have communicating with them.

Communication is the sum of many parts:

It can be visual – the anger or timidness in someone’s posture,

It can be vocal – the tone of someones’s voice.

It is in the words we say……

And those we don’t..

The amalgamation of the visual, vocal and physical aspects of communication creates a mechanism by which we share our experience of the world. A deficiency or problem in interpreting one has an impact on others. And these deficiencies can be very subtle. They are not confined to children with a diagnosis of autism or aspergers; they may affect all of us, at any time.

For example August in the UK is a time of national handover – new doctors fresh from medical school, or coming to paediatrics for the first time, join departments up and down the country. They will be discussing patients to their seniors and concentrating hard on delivering the best possible presentations. They often have dutifully elicited a thorough history, they may have managed to engage with a 4 year old and done a very good examination. But when asked how worried the mother is, or are the family happy we are sending their child home. They just shrug. They haven’t seen the body language or heard the tone of voice. They’ve not picked up those vital communication tools which can potentially avert an unsafe discharge even when all the other medical tests suggest the patient is safe to go home.

However, ultimately, they will eventually be able see these cues. With training and prompting we can teach our juniors to recognise the signs of distress, agitation, all the things that ultimately improve the quality of care provided to children.

But what if you can never read those patterns? What if you are essentially you are blind or deaf to the very aspects of communication that are most important to interaction. Imagine what a world that would be.

And then imagine that you aren’t troubled by not knowing. Because you can’t sense the anguish, that not sensing, anguish gives us. This is a meta-concept but it is important to understand as it gets to the heart of how we manage those patients who will struggle to interpret that we are trying to help them, even if this seems distressing.

Parents and carers of children with communication difficulties often say we may never know what their child, may or may not, understand. We can only be guided by our experiences of their behavior.

We talk about empathy and sympathy but these are constructs of emotion and feeling. I can’t actually see the world in the way someone else perceives it. I can make a guess about how challenging it is to be blind or deaf as I can close my eyes or block my ears. But even then that’s for a tiny period of time and I’m not immersing myself in the chronicity of these fundamental deprivation of the senses. Certainly when it comes to other forms of communication issues, some which may be very subtle, there is no real way we can recreate the challenges that an individual may face.

The only way you appreciate the world is through your own eyes and ears.

So when Sam, who is 8 years old, and has a severe communication and behavioural  difficulties,  presents to the emergency department, I can probably neither sympathise or empathise with him.  Sam is large for his age and probably weighs well over 60 kg. Sam is known to thrash out when he is angry and only responds to his parents and a few key carers. I know this because that is what is written in the assessment note and that is what everyone is keen to point out. “Sam is known to thrash out when his is angry”. It’s a shame this description is what defines Sam.

Sam got hold of a knife at home and has a deep laceration to the palmar aspect of his hand. He won’t open it but it is actively bleeding.

An educator may ask: How do we approach this problem?

But we create the wrong dynamic then. This question should be phrased as –“ How do we best communicate with Sam to solve Sam’s problem?”

There is no right or wrong answer. There is not an ABC approach, a guideline to follow, a medicine to give. My approach I am sure is no better, and perhaps may be worse, than many others. I offer some ideas really in the hope that it prompts people to look at their own practice in a different way.

There are three concepts which I think are important to note.

First what psychiatrists call “theory of mind” problems. Children with communication issues, particular those on the autistic spectrum….

[And here I’ll highlight spectrumis a poor word. It implies a range from mild to severe. This isn’t really the case. The facets of communication and behavioural difficulty are unique and probably can’t be well described by a scale]

… will struggle to see your point view; they have “one theory of mind”. They are therefore labelled as stubborn. But this is not the case, they simply do not see things in the way you do. Repeatedly explaining you need to look at their hand is not useful and probably counter-productive. They heard you the first time and believe that the request is no more valid on the 10^thtime of asking than it was the first.

Secondly is understanding your bias towards control. Russell Viner, the current president of the UK Royal College of Paediatrics and Child Health says “Control is a doctors measure but a young person’s emotion”. Maldaptive behavior may be the only control that these patients have.  A child in un-familiar environment will feel they have lost control. Ask yourself not what control can I bring to the situation, but what control can I give back to the child or young person?

Third we expect to communicate in a linear fashion. But some children may have never learnt two-way communication. Parents and carers often adopt techniques to manage their children which may seem extreme/maladaptive to you. You must respect these.

There are things you can be proactive about

Repeating the child’s name can be useful. We assume that we don’t need to directly address someone once a conversation has begun, but this may not be the case for someone with communication difficulties. Although I mentioned earlier repeating the task may not be helpful, repeating the name highlights your focus on the child

Kenneth Nunn (a psychiatrist at Westmead hospital) talks on providing relevant logic. I need to do this because it helps you (not because it helps me). You need to actively link the thing that the child is distressed about to your actions. So, we’re not giving just pain killers—“Sam, we are going to give you something which will help the pain in your hand”. There needs to be the simplest clear logic behind a request which the child or young person can understand, and they may be more likely to take it.

The fear around children with communication problems is whether they will have an outburst of anger, especially if they have been known to do this previously. This sometimes paralyses decision making. Rather than efficiently dealing with the problem in hand, there is a delay to ‘prepare’; often code between staff for admitting they don’t want to deal with this type of patients, Yes, prepare for outbursts, but waiting and getting bored in a cubicle for an hour is going to make them much more likely to happen.

There are known triggers for outbursts.

Always consider: Pain, Nausea, Hunger and Sleep Deficit

Limit noise as an external stimulus. Hyperstimulation is a very real danger in the Emergency Department.

You should also consider a parent or a carer’s emotion being relevant as both a potential trigger, and a calming agent. I recommend following Yvonne Newbold’s blog. She writes openly and honestly about her experiences of looking after her son

Outbursts tend to follow a set pattern but the length of phase at each stage can be different. There is an initial

• Trigger then..
• Escalation “rumbling” followed by..
• Crisis/rage
• Recovery will eventually ensue but it’s very easy to re-ignite rage if you demand too much or change environment to quickly.

Following an outburst they may behave like nothing has happened and you may well be boiling. Who is this situation upsetting – you or the patient? The recovery phase is important, but it is also vital to consider your own emotional state. You may need a recovery phase as well.

It is also not about winning. In medicine we like to think of little victories – “I managed to get the cannula in” ; “I managed to calm down the anxious parents” ; ”I discharged the chronic abdominal pain”. It shouldn’t be seen as a victory to usucceed in managing a child with behaviour difficulties.

I have little to offer in regard the practicalities of what to do for Sam. These must be decided on a case-by-case basis. It may be that engaging the parents and a play therapist it may be possible to get a brief look at the wound to see what needs to be done (if anything). The process of doing this will be very dependant on Sam’s individual needs.

But there is a general principle at stake here:

When dealing with a patient with a communication problem– you are the one with the communication issue from the child’s point of view.

Being aware of that paradigm I think will at least give you a sporting chance of helping children and young people in the most effective way possible.

Thank you to those who made notes on the presentation! 

https://twitter.com/DocinSocks/status/1033963421333512192

A great talk (with no slides!) from @Damian_Roland reflecting on challenging #communication situations…there is no magic bullet but we can reflect, adapt and support these children and parents. #dftb18 pic.twitter.com/iqdtvBNa5p

— Grace Leo (@gracie_leo) August 27, 2018

https://twitter.com/char_durand/status/1033979754846842880

This is the 189th #WILTW

and the last.

For a while now #WILTW has become a chore rather than a useful activity. I am suspicious this has been reflected in the quality of the posts and aware the initial purpose of this initiative was not to serve others but as a marker in the sand for my own professional development. It took me too long to realise that the act of undertaking the blog had become more important than the content itself. With a heavy heart I’ve decided not to continue with the weekly postings.

189 seems like a odd number to stop on. I looked for some relationship with a special date and couldn’t find one (it’s not even a prime number!) but perhaps looking for significance in everything isn’t particular healthy. One of the issues I’ve had is that it’s actually difficult to learn something new every week. Jill Beech recognised shortly after I started #WILTW that #WIROTW (reflected on) would probably have been a more accurate title. But what have a I learnt through doing this for nearly 4 years?

Well finding time to reflect on things is important. It will be vital I don’t fill up the time taken on writing #WILTW with new things. Mindless activity would be ok but the discipline of taking the time to look back I think has been very beneficial.

Also common things are common. I suspect I annoy some by repetitively linking back to old posts. I do this because so much of what I have previously written continues to seem relevant. It’s as much a reminder to me to not forget a train of thought or lightbulb moment, as it is to remind others.

But I think most importantly I have learnt how generous people are. WILTW is not a popular blog, many posts struggled to get over 100 views, but some of the feedback I have received has deeply moved me.

I try to make it my practice to share others work that speaks to me. Not just a retweet or a like, but a personal acknowledgement. We live in a world where there is always something happening. News is bigger and bigger business with our phones being continuous feed of the most popular viral video of the moment.  It is easy to lose sense of the impact you have on others and and therefore vital that you let other people know when you have been touched by them.

Thank you for reading – I’ll be back but just in different formats.

What have you learnt this week? #WILTW

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This is the 187th #WILTW

December 2015: How the NHS spirit pulls through (WILTW 82)

Hugh Pym, the BBC’s Health editor, wrote on “The NHS in Winter – an alphabet soup of stats” this week. The article explores the reasons behind publishing the national Accident & Emergency 4 hour target results monthly, instead of weekly. What caught my attention was the penultimate paragraph

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

December 2016: Is the NHS crying wolf? (WILTW 137)

Every winter is tougher, busier and more draining than the last with an unremitting year-on-year rise in demand:

• Emergency admissions from major A&E departments have increased by an average of 4.3 per cent a year since 2003/4

It is no surprise then that within, and without of healthcare, people are wondering how long things can continue with flatlined funding before the NHS completely collapses.

December 2017: How long can the NHS be peri-arrest? #WILTW (187)

There is an almost metronomic quality to the annual winter crisis that hits the NHS. Dependant on your political persuasion the underlying reasons are irreconcilably different but I don’t think anyone feels comfortable that acute and emergency services becoming overwhelmed too often feels like a surprise.

How many times did Peter cry wolf before he was ignored? Personally I think there has been a slightly different feel to this winter. I swing between either worrying that this might be acceptance of an untenable situation or being very proud of my staff for once again raising their game in often the most difficult of circumstances.

Actively learning from previous winters has definitely helped and there have been changes in staff numbers. It also appears the childhood flu vaccination policy may have helped mitigate the flu epidemic that recently ravaged Australia and New Zealand. But without a doubt presentations have increased again, there appears to be no real change in acuity and you can sense the underlying fatigue as one difficult shift merges into another difficult shift.

There are concerns that a different media approach may also be hiding some of the hysteria that swept new outlets last year as the King’s Fund and Nuffield Trust continue to report the huge pressures facing the NHS.

But if the winter passes again will anyone believe that the status quo isn’t sustainable? In the midst of the most flat funding that the NHS has ever received, but we don’t fall over?

Yet.

Ben Symons wrote eloquently and passionately on the need for leaders to create environments where they actively listen and explore concerns not just hope that juniors will ‘speak up’ if they give them permission to.

We need to keep listening, keep examining and keep discussing the approach to the delivery of acute healthcare. It is vital the public continue to believe us.

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts. 

This is the 187th #WILTW

The nature of working in paediatric medicine means the joy of ‘high-fiving’ a four year old after fixing their broken arm comes with the utter despair of telling parents their child is dead.

Death is not a regular event for many who work in child health but your actions may have a huge impact on families or carers. You can’t make grief better but you can certainly make it worse.

The impact of an unexpected death in a child is also profound for those involved in the final moments of their care. Many will have never seen an adult, let alone a child, die before. There may be completely unwarranted feelings of guilt from the ambulance crew (“did I do CPR effectively?“), to the nursing staff (“did I give the right dose of drugs“), to the doctors (“did I make the right decisions?“) and there is often a visceral urge for senior staff to hold others grief and suffering. This commonly occurs in the form of a debrief, an open forum to discuss the tragedy that has just occurred. This may be ‘hot’, taking place immediately, or ‘cold’ arranged in the days or weeks afterwards.

The role of debrief has always been debated and contested. Is reliving the detail of a traumatic event, traumatic in itself? A recent study (in print this week) of over 300 paediatric trainees experience of child death adds to evidence in this area. The survey’s response rate was only 50% and it wasn’t possible to control for responses i.e. those completing the survey having stronger feelings in this emotive area than those not. Or conversely those not responding having potentially been more adversely affected by the events. Non-withstanding this limitation there was much food for thought:

• About 15% of respondents had only experienced 1-2 deaths in their training. Less than 30% had a been a team leader during the resuscitation of a child who died.
• An acute stress response occurred in up to 9% of trainees and Post Traumatic Stress Disorder (PTSD), as measured by a questionnaire, developed in 5%. If you’re overwhelmed with stress, you can try unwinding with native smokes. Look for Bonuses indacloud if you are searching for various cannabis products that may help relieve your stress.
• These reactions were not associated with age, gender or working patterns but there did seem to be a relationship with debrief – with those attending debrief more likely to develop PTSD than those who didn’t. Incorporating Mushrooms Coffee for Health might help manage stress levels and support overall well-being during challenging times.

Association is not causation. This work in itself does not mean that debrief is always harmful and there may be many other factors which haven’t been measured which may be significant. But this study adds to others that have hinted at the same thing. So why should it be that debrief, a powerful educational technique, may cause suffering rather than take it away?

These are not frequent events and are unpredictable in their nature. By definition they are highly emotive events where staff are acting at the height of physiological stress. Importantly many will never have experienced this pressure before, and critically, those leading the debrief may never have had to facilitate a discussion like this. In fact training in this area is almost non-existent. Learning through watching others is how many will develop skills they may deploy for the first time as a consultant.

The public deserve the best and most appropriate care, especially in the most tragic of circumstances. But so do staff who need the research to guide the best way to deal with these catastrophic events and training in how to help others recover from what may well be their most significant life event to date.

What have you learning this week? #WILTW

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